Abstract

This article is written predominantly for healthcare assistants. It may also be useful for anyone less familiar with transferring patients or who delegates to HCAs.

It offers a definition of patient transfer and addresses considerations for patient safety and the role of HCAs throughout the three distinct phases of transfer, which are: preparation to transfer (before); considerations of transfer (during); and at the point of final handover (actual transfer) in a hospital.

It also addresses the role of escorting patients, and highlights the difference between transferring and escorting.

Finally, a framework for best practice is suggested, which could be applied in clinical areas where high proportions of patients are transferred, such as emergency departments, discharge lounges and admissions or assessment units. This framework is adaptable and can help in the development of local hospital policies for the safe transfer of patients.

The key message of this article is that patient transfer is a process that requires adequate preparation and occurs in distinct phases, each of which must be carried out with proper care and attention if patients are to be transferred safely

This article has been double-blind peer reviewed

Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page

5 key points

Assisting in transferring patients is an HCA responsibility in the majority of settings

HCAs need to be familiar with the potential risks a transfer can pose and know how to reduce these

In accepting the duty of transferring a patient, HCAs are accepting responsibility for that patient during transfer and must be competent to do so

A transfer checklist should be used to make sure all aspects of care are handed over

All patients’ medication, along with all information on it, must accompany them to the new area

The role healthcare assistants play in providing care is varied, and their specific duties differ depending on the clinical setting. However, assisting with the safe transfer of patients is a common aspect of the HCA role, regardless of where they work. Despite this, the education and training of HCAs in supporting the safe transfer of patients has received surprisingly little attention compared with the training of registered staff, in particular nurses (Skills for Health, 2011).

Hospitals need to constantly improve the way they manage and reduce the risk of patient harm by improving practice. The Royal College of Nursing has issued a position statement containing key principles regarding supervision and delegation that provides useful guidance for anyone developing training (RCN, 2012). The position statement suggests one of the ways to improve safety and reduce avoidable harm is to ensure HCAs are familiar with the potential risks involved in patient transfer and to adhere to a proposed framework of best practice.

Background

The role of HCAs is to accompany the patient/family, specifically to ensure patients experience a safe, comfortable and dignified transfer to and from a variety of settings.

Most patients who are being treated in hospital will be transferred between wards or departments for short periods of time for treatment or investigations, for example X-rays or ultrasound scans. In some areas, such as theatres and emergency departments, transferring patients can make up the majority of HCAs’ workload. In most cases, patient transfers will be uneventful and proceed without harm to the patient.

The Heart of England Foundation Trust (HEfT), along with all other trusts in the UK, reports incidents related to patient transfer where harm has occurred to the patient. In 2009, 8% of incidents reported by HEfT to the National Reporting and Learning Service were related to admission, transfer or discharge of patients (NRLS, 2009). Of these incidents, no harm was reported in 75%, low harm was reported in 15.6% and moderate harm reported in 8%, with serious harm occurring in the remaining 1.4% of incidents. These figures indicate that the trust has a better than average performance in this area compared with national data from other hospitals.

To protect patients, each year inspections are carried out to assess the trust’s risk management strategies. To date, training of HCAs in transfer has not been mandated, but it is being included in a new education programme for 2013.

Reducing identifiable harm

The HEfT corporate nursing team carried out a full review and drew up a new transfer policy to comply with NHS Litigation Authority regulations that help to protect patients from harm during transfer. Part of the hospital policy guidance comprises a set of standard operating procedures for each clinical area. A failure to comply with HEfT policies not only increases the risk of harm to patients but also may result in the trust being sued and significant financial penalties occurring.

To further reduce the possibility of harm, the communication and documentation of patient transfers has also been improved through the use of a transfer checklist, which contains information about the patient that will prepare the ward or department expecting the patient.

The transfer checklist is standardised across the trust and is based on the SBAR (situation, background, assessment and recommendation) model. SBAR is being promoted nationally in the NHS as a means of effective telephone communication, but it can also be used for emails, checklists and so on. The information on the transfer checklist includes details of the patient’s current clinical condition and whether or not the patient requires close observation on arrival to the new area.

The completion of relevant documentation and the communication of patient details needs continual improvement and HCAs can play a role in this. HCAs must communicate with their patients and with colleagues before and during patient handover.

Accepting delegated responsibility

Once an HCA has accepted the handover of a patient awaiting transfer, they are responsible for maintaining the patient’s safety. The delegation of the duty to transfer a patient must be made in accordance with hospital policy, which states that the HCA must be aware of the patient’s condition and understand any action that may be required in the event of deterioration or a change in condition during the transfer (Mulryan, 2009).

By accepting responsibility for patient transfer, a member of staff is accepting the duty of care to complete the task and must be competent to do so (RCN, 2011). If HCAs are unsure about whether they feel able to transfer the patient they must discuss this with the nurse responsible for the patient.

Points to consider when accepting a patient for transfer are listed in Box 1.

Handovers

Structured patient handovers of clinical information are the responsibility of registered nursing or medical staff. The patient information required to do this effectively will be in the medical notes, which must accompany the patient during transfer. This information will be used to complete the patients’ transfer checklist or will be handed over verbally on the telephone.

The HCA must ensure the patient transfer checklist accompanies the patient on transfer and that is given to the nurse accepting the patient (Hindmarsh and Lees, 2012). The duty of a HCA does not include the handover of clinical information but the HCA role is complementary because the HCA ensures the process is completed fully by providing all the relevant documentation and any further clarification required.

The risk in busy areas where there is a fast turnover of patients is that the HCA may be asked to transfer a patient with whom they are not familiar. To ensure safety, it is recommended that the transfer should not go ahead until the HCA has been given an adequate handover.

Many departments tend to ask HCAs to transfer patients, with the relative “risks” being informally assessed by a nurse. The nurse will need to rely on their experience and training, as well as their intuition, to make this judgement. The nurse should be able to weigh up clinical risks against the National Early Warning Score to guide the appropriateness and safety of the transfer.

The transfer process

If staff ensure that each stage of the process is completed satisfactorily, the entire transfer will be carried out safely.

Packing equipment and communicating to the patient about the change of setting are key parts of the preparatory stage. Depending on the patient, information about the move may have to be

reinforced immediately before transfer. Equipment used for transfer should be checked to make sure it is in working order, in particular oxygen or air cylinders (NRLS, 2009).

During the transfer, HCAs should always accompany the patient at the head of the bed or chair to ensure that they can observe for any clinical changes. They should not walk ahead or divert their attention away from the patient. If a patient becomes ill during transit, the patient needs to be taken back to the ward/department from where they were transferred for emergency help.

On arrival at the new ward or department, the HCA is responsible for ensuring a that a nurse is aware of the patient’s arrival and that the area is adequately prepared - for example, the items of equipment likely to be required are there, such as a drip stand, and that any of the patient’s property they have brought with them is placed safely in the locker by the bedside. It is good practice to unpack the property on arrival at the area of transfer - this should ensure that the patient and their relatives are satisfied that no property has been left behind. In some cases, the HCA completing the transfer may be required to contact relatives or provide the patient with the visiting times of the new ward.

Often medications belonging to the patient are left on the ward while the patient is transferred elsewhere. This has the potential to put the patient at risk, as well as increased costs if the medication is not transferred with the patient and needs to be reissued (Picton, 2012). The correct information with regards to medication must also be sent with the patient.

One of the core principles advocated by the Royal Pharmaceutical Society (Picton, 2012) is the “safe, effective transfer of information regarding medications” - the HCA transferring the patient plays a vital role in this process.

Types of transfer

There are many different types of patient transfer that occur every day in a hospital. Most commonly, these are patients who are being:

Admitted to hospital from emergency care settings;

Transferred to departments for investigations or treatment;

Transferred from one inpatient area to another to continue their care;

Transferred to intermediate care settings;

Discharged and transferred to the discharge lounge.

Transfers also take place outside hospital; these may be called transfers or discharges and may involve “escorting” the patient. Generally, if a patient is being transferred, they are being moved between care facilities, while a patient who is being discharged is going home or to a final destination, such as a nursing home.

Escorting patients

The role of escorting patients involves accompanying them over an extended period of time, possibly several hours, and includes a return journey; transferring patients does not usually involve a return journey to the same area.

Escorting duties involve assisting patients with their daily activities of living throughout the escort, usually involving helping them to use the toilet and to eat and drink.

This category includes:

Patients who require a specialist investigation being undertaken at another hospital;

Patients who are being transferred to a day care facility, such as intermediate care or a nursing home;

Home visits;

Patients who are undergoing surgical procedures as a day case.

Escorting duties will involve communicating with the patient, their relatives and the ward to maintain patient safety and dignity throughout the escort.

Conclusion

The transfer of patients between wards and departments involves an element of potential risk created by moving patients from a place where staff are familiar with them and their individual needs to an area where they are not known.

The HCA needs to ensure staff on the new ward are familiarised with the patient to reduce risks. The transfer of patients should not be undertaken without adequate preparation and staff must ensure that handover and communication/documentation are sufficient to transfer the patient safely.

By undertaking patient transfers, HCAs are acting as the patient’s advocate and represent the patient during the transfer.

A best practice framework (Box 3) has been devised that could be used within a standard operating procedure, local policy or guidance for induction to a new area.